The link between lower health literacy skills and worse health outcomes is robust and has been observed by investigators from multiple disciplines. Nonetheless, recent reports from the IOM and AHRQ identify several key gaps that hamper our understanding of health literacy, its impact on health outcomes, and its contribution to health disparities. These gaps include the lack of research on oral and aural language skills, the lack of understanding of the role of background knowledge, and the need to identify causal pathways through which literacy affects health. This proposed project addresses each of these gaps, expanding our understanding of the relation between health literacy and cardiovascular disease (CVD), a leading cause of death and disability. This proposed project (R21) will employ novel statistical approaches around an established community-based birth cohort of over 600 individuals, now in their 40s, who recently completed a follow-up study focusing on pathways linking education and health. A major strength of these recently collected data is that they are the first of their kind to contain individual assessments of both oral and aural skills and of reading and numeracy. As such, we are uniquely positioned to extend current research, which has largely focused on reading skills, and to fill an existing gap in the current knowledge base by conducting a comprehensive assessment of the association between literacy skills and CVD-related outcomes. Another distinctive aspect of the data is that they contain reliable measures of health endpoints related to CVD, including medical diagnoses, risk factors such as measured blood pressure and cholesterol, and health self-management. Finally, we have reliable measures of background health knowledge, as well as potential pathways linking literacy and health, including participatory decision-making (PDM) and navigation of the health care system. Taken together, these data allow for a unique and comprehensive examination of the association between health literacy and cardiovascular disease, assessed through the following three aims. Aim 1 identifies the magnitude of the association between reading, writing, oral language, and aural language and CVD diagnoses, risk factors, and health self-management and identifies combinations of literacy skills most predictive of these outcomes. Aim 2 examines the main and interactive effects of health knowledge and literacy skills on the CVD-related outcomes described above, testing the hypothesis that the association between literacy and health will be stronger for individuals with a higher level of health knowledge. Aims 3a and 3b assess how much PDM and systems navigation mediate the association between literacy skills and CVD-related outcomes and identify combinations of literacy skills most predictive of these pathways. Given the richness of these data to address a number of significant gaps in the current state of knowledge, the proposed project should yield a variety of new basic and applied information and contribute to the development of new measures of the oral exchange within a health context. PUBLIC HEALTH RELEVANCE: The public health, medical, and educational implications of this proposed project are considerable and include heightening public and policy awareness of the impact of literacy on health and cardiovascular disease;strengthening the link between the health and education professions;providing concrete recommendations for teachers and educational policymakers about which skills are most effective for managing and maintaining one's health;and suggesting specific targets for public policies, programs, and interventions aimed at reducing health disparities and improving the health and welfare of disadvantaged populations.